Evidence-Based Patient-Centered Needs Assessment

AORN Journal  1  

PRESIDENT’S MESSAGE

The Challenges of Ethical Decision Making in Nursing

Vangie Dennis, MSN, RN, CNOR, CMLSO

The profession of nursing is rife with decisions that can be difficult and challenging. Nurses have a responsibility to patients, health care team

members, and our profession to ensure ethical decisions are upheld in the organization and in practice. Our mor- al and ethical value systems are frequently challenged. As a result, nurses often struggle with making correct decisions.

Nurses’ unspoken pledge to duty is an integrated and fundamental part of nursing practice that holds nurs- es accountable for the well- being of patients and their families, ensuring interventions are appropriate to optimize care. Another essential principle that under- lies nursing practice is respect for the intrinsic dignity, value, and rights of all individuals.1 Nurses are hard- wired and committed to providing optimal care to their patients while respecting the rights and decisions of individuals; however, sometimes care requirements can interfere with what we believe are the correct decisions. Thus, it is essential for nurses to understand and demonstrate competency in providing ethical care. According to AORN’s Perioperative Explications for the ANA Code of Ethics for Nurses With Interpretive Statements, “Ethical practice is … a critical aspect of nursing care, and the development of ethical com- petency is paramount for present and future nursing practice.”2(p2)

ETHICAL DILEMMAS At times in nursing, our personal morals cannot determine the course of action and can conflict with decisions. In such situations, called ethical dilemmas,

the nurse is expected to choose between different options. The nurse is conflicted because each of the opposing choices is eth- ically supported while at the same time each of the opposing choices is also considered ethically problematic.3(p1517)

Nurses find themselves confronted with ethical dilemmas daily that may occur during patient care or other work- place activities; many of these can be categorized as world- imposed dilemmas or moral uncertainties.

World- imposed ethical dilemmas are when decisions are being determined by an outside force and there is no option to make an independent decision. In such instances, the nurse is bound to follow outside instruc- tion based on the current situation. Nurses are faced with decisions that may be forced upon them because of policies, administrative decisions, or management direc- tion. For example, the current nursing shortage has led to inadequate staffing that has affected care decisions. In my organization and many others, the coronavirus disease 2019 (COVID- 19) pandemic affected how we staffed perioperative areas, such as the postanesthe- sia care unit, with less- than- optimal nurse- to- patient ratios. Nurses felt overworked and questioned whether care was being compromised, but they submitted to the staffing model even though it conflicted with what they believed optimal care should be. In addition, there was a rush to fast- track personnel into specialty areas with- out adequate training because of staffing needs. Nurses were sometimes deployed to specialty areas without having the skills and competencies needed to care for the specific patient population.

http://doi.org/10.1002/aorn.13733 © AORN, Inc, 2022.

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July 2022, Vol. 116, No. 1Dennis

Moral uncertainty can be thought of as what a virtuous person would do, or what is right to do, despite individuals’ own personal beliefs about the situation. The conclusion does not guarantee that they are correct. Many times, an individual can become morally biased because of vested interests, peer influence, culture, religion, upbringing, or influence from the status quo.4 Nurses often find them- selves doubting their own beliefs and decisions. Moral uncertainty impacted health care during the pandemic. For example, as part of providing appropriate care, nurses try to ensure that patients and their families have adequate emotional support. However, the COVID- 19 pandemic limited the ability for families to be with their loved ones; at times, patients died without their loved ones by their side. My last place of employment realized the importance of family member presence during the end- of- life stage and implemented a practice called “No One Dies Alone” so loved ones could be with their family member during their passing.

Moral uncertainty also can arise in situations in which patients refuse care or certain care approaches. For example—as nurses, although we know the various treatments for breast cancer, there are patients who do not want to proceed with radical treatment. A nurse could become judgmental and assume this is what the patient should do for themselves and their family. However, nurses should not impose their own views on patients.5

Cultural Considerations The focus on cultural competency is how the caregiv- er responds to the value systems of our diverse pop- ulation. The multigenerational workforce of today can influence the quality of care and staff member interac- tion. Generational differences among employees can be beneficial to an organization because diversity nurtures inventiveness and a differentiated approach to problem- solving. When nurses do not understand cultural compe- tency, the results can affect our care and create ethical dilemmas. An individual’s value systems— whether the individuals are nurses or patients— can influence the decisions we make. The importance of not generalizing individuals and instead attempting to understand, relate to, and appreciate the behaviors of members from all generations is instrumental in understanding genera- tional differences and maintaining effective and satisfy- ing relationships at work.6 It is critical for us to acquaint

ourselves with the patient’s culture to fully understand their behavior within the cultural context.7

CONCLUSION Perioperative nursing presents its own unique challenges, and there have been unprecedented levels of transforma- tion over the last decade that have affected our ethical decisions regarding patient care. Nurses are among the most critical stakeholders in all of this change. Together, we must develop opportunities while collaboratively pro- moting processes that involve team members as part of the decision- making process. It is important that nurses comprehend the impact of the ethical decisions we make; although ethical decisions may not always be clear, they should always be made with the patient’s best interests in mind.

REFERENCES 1. Nursing: Scope and Standards of Practice. 3rd ed. Silver

Spring, MD: American Nurses Association; 2015.

2. AORN’s Perioperative Explications for the ANA Code of Eth- ics for Nurses With Interpretive Statements. Denver, CO: AORN, Inc; 2017. https://aorn.org/guide lines/ clini cal-resou rces/code-of-ethics. Accessed May 24, 2022.

3. DeKeyser Ganz F, Berkovitz K. Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. J Adv Nurs. 2012;68(7):1516- 1525.

4. MacAskill W, Bykvist K, Ord T. Moral Uncertainty. Oxford, UK: Oxford University Press; 2020.

5. Brink H. The science of nursing: current issues and dilem- mas. Curationis. 1992;15(2):12- 18.

6. Stokowski LA. The 4- generation gap in nursing. Medscape. http://www.medsc ape.com/viewa rticl e/781752_2. Published April 11, 2013. Accessed April 25, 2022.

7. Diller JV. Cultural Diversity: A Primer for the Human Services. 5th ed. Stamford, CT: Cengage Learning; 2015.

Vangie Dennis, MSN, RN, CNOR, CMLSO, is the AORN President and an assistant vice president of Perioperative Services, AnMed Health, Anderson, SC. Ms Dennis has no declared affiliation that could be perceived as posing a poten- tial conflict of interest in the publication of this article.

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